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Caregiver Application for Respite Voucher

Thank you for your interest in receiving respite voucher through Lifespan Respite Washington.

To best work with you and the care recipient, please fill out as much of the form below as you are able to. All questions that have asterisks (*) are required. All other questions help us determine eligibility and need of all applicants.

Optional: What is your relationship to the person you provide care for? I am their:

Eligibility and Need

I provide 40 or more hours of care, supervision, or monitoring per week.

YesNo

I receive respite care through Medicaid or other program that provides respite care.

YesNo

If yes, please enter the program's name

I have received a Lifespan voucher in the past.

YesNo

How long since you last received a break from caregiving?

How long have you been an unpaid caregiver? (optional)

What has primarily kept you from having breaks in the past? (optional)

Other - please describe

Optional: What else has kept you from having breaks in the past?

Money

Transportation

Timing

Available Provider

What type of respite support is primarily needed?

Other - please describe

Optional: What other types of respite support are needed?

In-home

Day services

Overnight services

Camp

Recreation

Unsure

Information about the person receiving care

Name of person you provide care for

Birthdate of person receiving care

(MM/DD/YYYY)

Care Recipient Gender

Care Recipient Zip Code

Care Recipient County

Does the person you provide care for have a disability or special health care need?

YesNo

Primary disability or special healthcare need

Secondary disability or special healthcare need (optional)

Other notes or information about special healthcare need

Race of person you provide care for (select all that apply)

Caucasian/White

Black or African American

American Indian/Native American/Alaska Native

Asian

Pacific Islander/Native Hawaiian

Two or more races

Prefer not to answer

Ethnicity of person you provide care for

Is the care recipient currently receiving paid services from the DDA (Developmental Disabilities Administration)?

YesNo

Is the care recipient's insurance coverage Medicaid or Apple Health?

YesNo

Authorized Representative Information

If you are an Authorized Representative - a person authorized by you to exchange information for the purposes of facilitating respite care - and you are completing this application on behalf of a client, consumer, and/or individual for which you have a professional relationship please CHECK this box to insert your contact information.

Name

Agency

Title/Relationship

Email

Phone

I will submit additional documents to authorize this referral

By uploading the documentation to this formVia email within the next 3-5 business daysNot applicable for this referral

Please upload document(s) to authorize referral

Maximum file size is 50MB

Acknowledgement/Agreement

I have reviewed the eligibility on the Lifespan Respite Washington website also available at this link: https://www.lifespanrespitewa.org/voucher-program/ to understand how the Lifespan Respite voucher applies to my situation. I attest that all the information on this application
is true and accurate.

If, during the application process, my care-giving situation changes (e.g., I am no longer providing
40+ hours per week or I receive respite elsewhere), I understand my voucher may be given to
another eligible family caregiver.

I understand I am responsible for selecting a respite provider who will be paid when I indicate I've received the services they are billing to receive their payment.

I understand that my respite provider may not provide transportation to me/I cannot ride in their vehicle unless the agency as a part of its work provides transportation (e.g. camp, Adult Day Health facility, educational or recreational organization, etc.) and they have provided their insurance certificate to PAVE.

I authorize the exchange of information, including from this application, via common methods
(phone, in person, postal mail, fax, email, data entry) among all relevant parties, including formal
respite programs to verify, coordinate, and deliver services on behalf of my care receiver and
myself.

Indemnification. By selecting the respite provider of his/her own free will, the unpaid, un-served
caregiver shall indemnify, defend, and hold harmless PAVE and Lifespan Respite Washington, the State of
Washington, the United States Government and the Respite Provider Agency from and against any
and all claims, demands, suits, liabilities, and judgments, including attorney’s fees and claims for
bodily injury or death, arising from services rendered or for facilities provided with the operation of
the LRW Voucher Program.

Please type the word AGREE in the box below, to confirm you accept the terms above.

Please type your name, which will serve as your electronic signature.

If you have additional questions and/or will be sending us further documents, contact getrespite@wapave.org.